Rate, causes, and risk factors of caesarean section in

north of Jordan and its associated maternal and

perinatal risks

Jordan University of Science and Technology

Prof. Yousef Saleh Khader

Prof. Anwar Batieha
Dr. Shadi Khader
Dr. Miassar Al Jalam
Dr. Isra Abu Amra
 Executive summary

Caesarean section (CS) is a life-saving surgical procedure when certain complications arise
during pregnancy and labour. However, it is a major surgery and is associated with immediate
maternal and perinatal risks and may have implications for future pregnancies as well as long-
term effects that are still being investigated. The World Health Organization (WHO)
recommends that the rate of CS should not exceed 10-15% in any country. In recent years, the
rate of cesarean deliveries increased dramatically worldwide with many countries had exceeded
the WHO recommended rate. One study in Jordanian University Teaching hospitals showed that
the rate of CS increased from 18.2% in 2002 to 30.3% in 2012. The current study aimed to
determine the extent, causes, and factors associated with cesarean deliveries in north of Jordan
and their associated maternal and neonatal outcomes.

A prospective hospital-based longitudinal study was conducted to determine the rates, causes,
and risk factors of CS in north of Jordan. Women were enrolled in the study after delivery,
shortly before or at the time of discharge from the selected health facilities. All women who
gave birth (dead or alive) at 20 weeks of gestation or more in four selected hospitals were
eligible for inclusion. Necessary data for mothers including socio-demographic, clinical,
maternal, pregnancy, delivery and other risk factors were gathered through face-to-face
interview using a semi-structured questionnaire and by abstraction of data from medical records.
All information in the study questionnaires including causes of CS were confirmed by
physicians.

The overall rate of CS was 37.5% among Jordanian women. The rates were 16.3% for
emergency CS and 21.2% for planned CS. The rate of CS varied significantly according to
health sector. The rates of planned CS were 27.0% in teaching hospitals, 26.7% in military
hospitals, 18.6% in public hospitals, and 10.1% in private hospitals. The rates of emergency CS
were 15.3% in teaching hospitals, 13.8% in military hospitals, 20.1% in public hospitals, and
14.3% in private hospitals.

The most frequent reason for planned CS was scarred uterus (50.0%). The second most common
reason was multiple fetuses (20.8%). Other relatively common reasons included abnormal
presentation (7.6%) and mothers’ desire for CS (6.9%). The most frequent reasons for
emergency CS were prolonged fetal distress (33.5%) followed by obstructed labor (22.2%),
abnormal presentation (13.1%), and eclampsia or sudden severe high blood pressure or seizure
(6.3%).
Health sector was not significantly associated with the rate of planned CS after adjusting for
important variables. The odds of planned CS among women aged 20-35 and >35 years were 7.5
and 38.2 times that odds among women aged <20 years, respectively. Income of >350 was
significantly associated with increased odds of planned CS by two times. Women with previous
cesarean section had much higher odds to be planned for CS (OR = 30.1). Breach presentation
was associated with a very high odds of planned CS (OR = 245). Women with multiple fetuses
were 13.2 times more likely to deliver via planned CS compared to women with single fetus.
On the other hand, women with previous cesarean section had twice higher odds to deliver via
emergency CS (OR = 2.2) compared to women with no previous CS. Breach presentation was
associated with a very high odds of emergency CS (OR = 58.7). Having a boy baby, gestational
diabetes, and hospitalization between 24 and 34 weeks of gestation were significantly associated
with increased odds of emergency CS.
About 45.6% of newborns delivered vaginally had good Apgar scores at 1 minute (8-10)
compared to 46.2% for planned CS and 28.9% for emergency CS. The stillbirth rate was
significantly higher (p=0.000) for planned CS (1.7%) and vaginal delivery (1.5%) compared to
emergency CS (0.5%).
In conclusion, Jordan has a markedly high rate of CS. The rate of planned CS is higher than that
of emergency CS. Scarred uterus and multiple fetuses are the most common reasons for planned
CS. The main reasons for emergency CS are prolonged fetal distress, obstructed labor, and
abnormal presentation.
Based on the available data, we recommend the followings:
1. A multidisciplinary quality assurance program should be established in all Jordanian
facilities in which delivery occurs. As most CSs are currently based on physician’s
judgment, it may be extremely useful to develop and strictly implement national
guidelines for performing CSs.
2. Implement a policy of mandatory second opinion for all Cs (planned or not).
3. Make written guidelines available for all physicians at the hospital.
4. Implement the monthly medical audits of the obstetrical practice.
5. Get a commitment from hospital obstetric departments to work on lowering the C-
section rate.
6. Caesarean sections should ideally only be undertaken when medically necessary. Every
effort should be made to provide caesarean sections to women in need, rather than
striving to achieve a specific rate.
7. In making plans for delivery, physicians and patients should consider a woman’s chance
of a successful vaginal birth after cesarean (VBAC) as well as the risk of complications
from a trial of labor.
8. Implement in case of induction a policy of informed consent that allows the mother to be
fully informed of the possible consequences and benefits of an induction for non medical
reasons.
9. Multifaceted strategies, based on audit and detailed feedback, are advised to improve
clinical practice and effectively reduce caesarean section rates.
10. Alert patients about the true risks of major abdominal (C-section) surgery, compared to
normal vaginal deliveries.
11. Provide more training and support for women giving birth to twins to do so vaginally.
12. Mobilize an effort to evaluate the effectiveness and need for labor induction, continuous
fetal monitoring and epidurals because all of these procedures can lead to more C-
sections.
Introduction

Caesarean section (CS) is a life-saving surgical procedure when certain complications arise
during pregnancy and labour. However, it is a major surgery and is associated with immediate
maternal and perinatal risks and may have implications for future pregnancies as well as long-
term effects that are still being investigated (1–4). The use of CS has increased dramatically
worldwide in the last decades particularly in middle- and high-income countries, despite the lack
of evidence supporting substantial maternal and perinatal benefits with CS. Some studies had
shown a link between increasing CS rates and poorer outcomes (5, 6). The reasons for this
increase are multifactorial and not well-understood. Changes in maternal characteristics and
professional practice styles, increasing malpractice pressure, as well as economic,
organizational, social and cultural factors have all been implicated in this trend (7–10).
Additional concerns and controversies surrounding CS include inequities in the use of the
procedure, not only between countries but also within countries and the costs that unnecessary
caesarean sections impose on financially stretched health systems (11, 12).

Country-level CS rates worldwide were compiled and global and regional estimates were
generated and published in 2007 (13). According to the latest data from 150 countries, 18.6% of
all births occur by CS, ranging from 6% to 27.2% in the least and most developed regions,
respectively. Based on the data from 121 countries, the trend analysis showed that between 1990
and 2014, the global average CS rate increased 12.4% (from 6.7% to 19.1%) with an average
annual rate of increase of 4.4%.

The World Health Organization recommends (WHO) that the rate of cesarean section (CS)
should not exceed 10-15% in any country (14). In recent years, the rate of cesarean deliveries
increased dramatically worldwide with many countries had exceeded the WHO recommended
rate (15). Similar to other countries, the rate of CS in Jordan is high exceeding the WHO
recommendation (16). One study in Jordanian Teaching hospitals showed that the rate of CS
increased from 18.2% in 2002 to 30.3% in 2012 with the most common reason for CS being
“absence of a clear indication” (16).

Many factors have been identified to be associated with CS across the world such premature
rupture of the amniotic fluid membrane, cephalic pelvic disproportion, fetal distress, multiple
pregnancy, breech presentation, place of health seeking (private/ public), maternal preferences,
birth weight, parity, maternal height and history of antenatal care visit (17-23).
The main indications for cesarean delivery are previous cesarean delivery, breech presentation,
abnormal labor, and fetal distress (24). However, when a CS is performed without medical need,
it puts mothers and their babies at risk of short- and long-term health problems. Most
complication of CS comes from the cause which leads to CS. Risks of short-term and long-term
maternal and infant morbidity associated with elective caesarean section are higher than those
associated with vaginal birth (25-27).

General objective: Determine the extent, causes, and factors associated with cesarean
deliveries in north of Jordan and their associated maternal and neonatal outcomes.

Specific objectives:

1. Determine the rate of CS among Jordanian women in north of Jordan

2. Determine the causes and risk factors of CS in north of Jordan
3. Identify the associated maternal and perinatal outcomes (risks) of CS in north of Jordan.

Methods

Study design

A prospective hospital-based longitudinal study was conducted to determine the rates, causes,
and risk factors of CS in north of Jordan. Women were enrolled in the study after delivery,
shortly before or at the time of discharge from the selected health facilities. All women who
gave birth (dead or alive) at 20 weeks of gestation or more in each of the selected hospitals were
eligible for inclusion. Necessary data for mothers including socio-demographic, clinical,
maternal, pregnancy, delivery and other risk factors were gathered through face-to-face
interview using a semi-structured questionnaire and by abstraction of data from medical records.
All information in the study questionnaires including causes of CS were confirmed by
physicians.

Study setting / data sources

The study took place in 4 major maternity hospitals in Irbid governorate in north of Jordan; one
public hospital, one military hospital, one teaching hospital, and one private hospital. The main
researcher was responsible for overseeing the day-to-day work and ensuring the quality of data
and monitoring progress, and for training the study team.
Study population

The study population included all women who will give birth (dead or alive) after 20 weeks of
gestation during the study period in the selected four hospitals regardless the mode of delivery.
The four hospitals serve women from all parts of the north of Jordan. Women who gave birth in
the selected hospitals were heterogeneous in terms of socio-economic status, residency are (rural
and urban), and clinical characteristics. The teaching hospital is a referral center for women
from different parts of the north of Jordan. Although the settings were four hospitals in the same
city but they serve different populations. All hospitals have a 24-hour in-house attending
specialist or faculty coverage, and most births are attended by residents with specialist or faculty
supervision.

Sample size

The sample size was determined for the purpose of estimating the rate of CS and determination
of the association between any independent variable (Z) and CS. At a confidence level of 95%,
the minimum sample size needed to estimate the expected CS rate of 30% (a rate that was
estimated in a study in Jordan in 2012 (16) with a precision of 5% was calculated as 608. The
sample size was planned to be increased to more than 1200 women to have an expected 360 CS
cases to give a better picture on the indications of CS and its association with rare risk factors.
The power to detect a clinically significant association (odds ratio of 1.5) between any
independent important factor and CS or between CS and any associated outcome (in a case-
control analysis plan using logistic regression analysis) is exceeding 80%. The number of
women selected from each hospital was proportional to the number of deliveries in each
hospital. Sample size calculations were performed using EpiCalc 2000 and G*Power 3.1

Data collection

Necessary data for mothers and their newborns including socio-demographic, clinical, maternal,
pregnancy, delivery and other risk factors were gathered through face-to-face interview using a
semi-structured survey instrument (Annex 1) and review of the medical records. Data on
cesarean delivery including cause, whether the CS was planned or emergency, and the
occurrence of any complications were ascertained by the obstetrician. Questions were grouped
in sections, positioned in a logical order, and clearly numbered to lessen the chance of getting
lost in using this long survey. A consent form was developed with an introductory paragraph
explaining the purpose of the survey, asking for permission to do the interview and stating that
the information obtained during the study is confidential.
The questionnaire included questions about factors that might be associated with CS and its
associated maternal and perinatal outcomes including demographic (age of mother; education of
mother); socioeconomic (socioeconomic status, employment status of mother and father), and
family characteristics (birth order; birth interval); antenatal factors (routine visits, identification
and appropriateness of management of complications, counseling for birth preparedness and
breastfeeding); clinical characteristics (Preeclampsia, diabetes mellitus, high blood pressure,
anemia, etc.); delivery factors (length of gestation, location of birth, birth attendant, type of
delivery, mechanical assistance; Fetal outcomes (stillbirth, Apgar score at 5min , Apgar score1
min).

The baby was scored at 1 and 5 minutes after birth. Apgar score was classified as: A score of 8–
10 is considered normal, 4–7 is intermediate, 0–3 is poor and the infant requires immediate
resuscitation. Data about gestational age were recorded in the study questionnaires based on
what reported by practicing physicians, based on both ultrasound and the last menstrual period.
It was calculated as the interval between the date of delivery of the fetus or newborn and the
first day of the mother's last normal menstrual period. A premature baby is born before 37
completed weeks of pregnancy. Based on the gestational age, preterm babies were further
classified as follows: Preterm babies are born between the gestational ages of 32-36 weeks of
gestation, as calculated from the mother’s last normal menstrual period; Very preterm babies are
born between the gestational ages of <31 weeks.

A stillbirth was defined as any fetus born without a heartbeat, respiratory effort or movement, or
any other sign of life. Preeclampsia was defined according to International Society for the Study
of Hypertension in Pregnancy (ISSHP). Obesity was defined according to body mass index
(BMI) and it was calculated as pre-pregnancy women weight in Kg divided by height in meters
square. A woman with BMI > 30 kg/m2 was considered as obese.

Data management plan

Data were analyzed using the Statistical Package for Social Sciences (SPSS IBM 20). The rate
of CS, overall and by relevant variables were calculated. The differences in CS rates according
to studied variables were tested using Chi-square test. Multivariate analysis using logistic
regression was conducted to determine the factors associated with CS. We assessed the presence
of multicollinearity among the selected independent variables using cross-tabulations which
showed a strong correlation between some independent variables. Several variables were
involved in interdependencies. To deal with the multicollinearity in other variables, different
regression models were developed. The effect of variables was tested by adding one variable
each time. The variables that were not significant in this step were excluded from the model.
The adjusted odds ratios and 95% confidence intervals (CIs) were determined for variables in
the constructed models. The outcomes of cesarean delivery for the baby were obtained and
compared with the rest of the deliveries in bivariate and multivariate models. The frequencies of
the different causes for CS were also obtained. CS was classified into emergency and planned
and the frequency of each, overall and by relevant variables were obtained. A p-value of less
than 0.05 was considered statistically significant.

Coordination, monitoring and quality control

Before and during data collection, a quality control process was implemented to ensure quality
of the data. The principal investigator provided close supervision of every step of data collection
and data entry in order to maintain data quality. In all phases of this study, close coordination
was assured between the principal investigator and the data collectors. This was achieved
through phone calls, meetings, and arranging site visits. The study questionnaire were developed
and structured carefully to avoid confusion and minimize possible errors.

Ethical considerations:

Ethical approval of the study was obtained prior to implementation. The importance of
confidentiality and the protection of the identity of respondents was emphasized during training
of the study team and as a part of the continuing supervision during data collection. A verbal
informed consent was obtained from all participating women. Every effort was made to protect
the confidentiality and the identity of participants. During data collection, participants had the
full right to drop out at any time during the study and to not respond to questions they did not
wish to answer. No harm to participating hospitals was anticipated because the study results
were reported as overall estimates. No reporting by individual hospitals was carried out so that
the interests and privacy of the individual hospitals were protected.
Results

Rate of Cesarean Section

A total of 1347 women were enrolled in this study. The overall rate of CS was 37.5% among
Jordanian women. The rates were 16.3% for emergency CS and 21.2% for planned CS. The rate
of CS varied significantly according to health sector. The rates of planned CS were 27.0% in
teaching hospitals, 26.7% in military hospitals, 18.6% in public hospitals, and 10.1% in private
hospitals. The rates of emergency CS were 15.3% in teaching hospitals, 13.8% in military
hospitals, 20.1% in public hospitals, and 14.3% in private hospitals. Overall, the highest rates of
CS were in teaching and military hospitals (Figure 1).

Figure 1. The rate of emergency and planned caesarean section according to health sector.

Emergency CS Plannned CS
30.0% 26.7% 27.0%

25.0%
20.1%
20.0% 18.6%
14.3% 15.3%
13.8%
15.0%
10.1%
10.0%

5.0%

0.0%
Private Public Military Teaching

Rate of CS according to socio-demographic characteristics

Table 1 shows the mode of delivery for Jordanian women according to their socio-demographic
characteristics. The rate of planned CS increased significantly with increasing age, being the
highest among women who were older than 35 years (44.6%). The rate differed significantly
according to occupation. The rate of planned pregnancy was significantly higher among
employed women compared to housewives (25.8% vs. 20.1%). The rate of emergency CS was
significantly higher among women who delivered boys compared to those who delivered girls
(19.1% vs. 13.2%). The rate of CS did not differ significantly according to mothers' and fathers'
education and income.
Table 1. Mode of delivery among Jordanian women according to socio-demographic
characteristics.

Mode of delivery
Vaginal Emergency Planned CS Total
delivery CS
n % n % n % N p-value
Age (year) <0.005
<20 49 76.6 12 18.8 3 4.7 64
20-35 728 64.7 183 16.3 214 19.0 1125
>35 61 38.9 26 16.6 70 44.6 157
Mother's education
<12 165 64.5 48 18.8 43 16.8 256 0.207
12-14 392 61.4 96 15.0 150 23.5 638
>14 282 62.3 77 17.0 94 20.8 453
Father's education
<12 190 59.7 62 19.5 66 20.8 318 0.483
12-14 419 63.5 104 15.8 137 20.8 660
>14 230 62.8 54 14.8 82 22.4 366
Income (Jordan Dinars)
≤350 522 64.0 136 16.7 158 19.4 816 0.095
>350 317 59.7 85 16.0 129 24.3 531
Occupation
Housewife 682 63.9 171 16.0 215 20.1 1068
Employee 157 56.3 50 17.9 72 25.8 279
Baby's gender 0.013
Male 427 60.1 136 19.1 148 20.8 711
Female 412 64.8 84 13.2 140 22.0 636

Rate of CS according to clinical characteristics

Compared to women with normal blood pressure, the rates of planned CS (30.9% vs. 20.9%) and
emergency CS (27.3% vs. 15.9%) were significantly higher among women with hypertension
(Table 2). Preeclampsia was significantly associated with higher rate of planned CS (51.6% vs.
20.6%) and lower rate of emergency CS (9.7% vs. 16.6%). The rate of planned CS was
significantly much higher among women with pregestational diabetes, while the rate of
emergency CS was much higher among women with gestational diabetes. Women who were
hospitalized between 24 and 34 weeks of gestation were more likely to be planned for CS.

Table 2: Mode of delivery among Jordanian women according to clinical characteristics.

Mode of delivery
Vaginal Emergency Planned Total
delivery CS CS
n % n % n % N p-value
Anemia
Yes 136 62.1 29 13.2 54 24.7 219 .226
No 703 62.3 192 17.0 233 20.7 1128
Urinary tract infection
Yes 139 65.9 27 12.8 45 21.3 211 .286
No 700 61.6 194 17.1 242 21.3 1136
High blood pressure
Yes 23 41.8 15 27.3 17 30.9 55 0.005
No 816 63.2 206 15.9 270 20.9 1292
Preeclampsia <0.005
Yes 12 38.7 3 9.7 16 51.6 31
No 827 62.8 218 16.6 271 20.6 1316
Diabetes
No diabetes 831 62.8 214 16.2 278 21.0 1323 .018
Gestational diabetes 6 35.3 6 35.3 5 29.4 17
Pregestational diabetes 2 28.6 1 14.3 4 57.1 7
Hospitalization between 24 and <0.005
34 weeks of gestation
Yes 37 33.3 22 19.8 52 46.8 111
No 802 64.9 199 16.1 235 19.0 1236
Rate of CS according to obstetric characteristics
Table 3 shows the mode of delivery among Jordanian women according to obstetric
characteristics. The rate of planned pregnancy was higher among women with history of
low/preterm delivery (38.9% vs. 20.3%), history of previous CS (66.2% vs. 10.4%), history of
stillbirth/neonatal death (42.9% vs. 20.0%), and history of abortion (28.3% vs. 18.8%). It seems
that these women with history of these conditions were more likely to be planned for CS leaving
the rate of emergency CS being lower in this group of women. The rate of planned CS increased
significantly with increased number of deliveries while the rate of CS was the highest for
primiparous women.

Table 3. Mode of delivery among Jordanian women according to obstetric characteristics

Mode of delivery
Vaginal Emergency CS Planned CS Total
delivery
n % n % n % N p-value
Number of fetuses .053
Single 819 65.5 209 16.7 222 17.8 1250
Multiple 20 20.4 12 12.2 66 67.3 98
History of low/preterm <0.005
delivery
No 799 62.7 217 17.0 259 20.3 1275
Yes 40 55.6 4 5.6 28 38.9 72
History of previous CS <0.005
Yes 58 22.1 31 11.8 174 66.2 263
No 781 72.0 190 17.5 113 10.4 1084
History of <0.005
stillbirth/neonatal death
No 810 63.8 206 16.2 254 20.0 1270
Yes 29 37.7 15 19.5 33 42.9 77
History of abortion <0.005
Yes 197 54.6 62 17.2 102 28.3 361
No 642 65.1 159 16.1 185 18.8 986
Time of first antenatal
 1st trimester 803 61.9 217 16.7 277 21.4 1297 .239
2nd trimester 25 69.4 2 5.6 9 25.0 36
3rd trimester 4 66.7 2 33.3 0 0.0 6
No visit 7 87.5 0 0.0 1 12.5 8
Number of antennal care .301
visits
None 7 87.5 0 0.0 1 12.5 8
1-8 113 67.3 22 13.1 33 19.6 168
>8 719 61.4 199 17.0 253 21.6 1171
Number of deliveries <0.005
1 255 62.5 100 24.5 53 13.0 408
2 232 69.5 43 12.9 59 17.7 334
3-4 233 59.1 49 12.4 112 28.4 394
≥5 119 56.4 29 13.7 63 29.9 211

Reasons for Planned CS

Table 4 shows the various reasons for planned cesarean section according to health sector. The
most frequent reason was scarred uterus (50.0%). The second most common reason was
multiple fetuses (20.8%). Other relatively common reasons included abnormal presentation
(7.6%) and mothers’ desire for CS (6.9%). The distribution of these reasons varied significantly
according to sector. For example, scarred uterus was the common reason in public sector
(63.5%) and lowest in military and teaching hospitals.

Table 4. The reasons for planned cesarean section among Jordanian women according
to sector

Health sector
Private Public Military Teaching Total
n % n % n % n % N %
Scarred uterus 11 50.0 54 63.5 37 40.7 42 46.7 144 50.0
Multiple fetuses 1 4.5 16 18.8 23 25.3 20 22.2 60 20.8
Placenta previa / 0 0.0 2 2.4 2 2.2 3 3.3 7 2.4
malposition
Large fetus 2 9.1 0 0.0 0 0.0 0 0.0 2 0.7
Mother's desire 1 4.5 4 4.7 5 5.5 10 11.1 20 6.9
Abnormal presentation 0 0.0 1 1.2 15 16.5 6 6.7 22 7.6
Special medical condition 0 0.0 0 0.0 3 3.3 1 1.1 4 1.4
others 2 9.1 1 1.2 4 4.4 3 3.3 10 3.5
Precious fetus 2 9.1 2 2.4 0 0.0 1 1.1 5 1.7
Old primi 1 4.5 1 1.2 0 0.0 0 0.0 2 0.7
Post date 1 4.5 2 2.4 1 1.1 0 0.0 4 1.4
Anterior posterior repair 0 0.0 1 1.2 0 0.0 0 0.0 1 0.3
Congenital anomaly 0 0.0 0 0.0 0 0.0 2 2.2 2 0.7
Bad obstetric history 0 0.0 0 0.0 0 0.0 1 1.1 1 0.3
Cephalopelvic disproportion 0 0.0 0 0.0 0 0.0 1 1.1 1 0.3
Oligohydraminous 1 4.5 1 1.2 1 1.1 0 0.0 3 1.0

Reasons for Emergency CS

Table 5 shows the various reasons for emergency cesarean section according to health sector.
The most frequent reason was prolonged fetal distress (33.5%) followed by obstructed labor
(22.2%), abnormal presentation (13.1%), and eclampsia or sudden severe high blood pressure or
seizure (6.3%). The distribution of these reasons varied according to health sector. For example,
obstructed labor accounted for 41.9% of emergency CSs in private hospitals as compared to
7.6% in public hospitals.

Table 5. The reasons for emergency cesarean section among Jordanian women according to
sector

Health sector Total

Private Public Military Teaching
n % n % n % n % N %
Eclampsia or sudden severe high blood 0 0.0 13 14.1 0 0.0 1 2.0 14 6.3
pressure or Seizure
Heavy persistent vaginal bleeding 2 6.5 2 2.2 2 4.3 0 0.0 6 2.7
Cephalopelvic disproportion 2 6.5 2 2.2 1 2.1 1 2.0 6 2.7
Obstructed labor 13 41.9 7 7.6 14 29.8 15 29.4 49 22.2
Failed vacuum or forceps delivery 0 0.0 0 0.0 0 0.0 2 3.9 2 0.9
Cord prolapse 1 3.2 1 1.1 2 4.3 2 3.9 6 2.7
Mother exhaustion 0 0.0 11 12.0 0 0.0 0 0.0 11 5.0
Abnormal presentation 1 3.2 18 19.6 5 10.6 5 9.8 29 13.1
Other mother reasons 3 9.7 7 7.6 2 4.3 0 0.0 12 5.4
Premature labor pain 1 3.2 1 1.1 0 0.0 0 0.0 2 0.9
Prolonged fetal distress 5 16.1 26 28.3 21 44.7 22 43.1 74 33.5
Other fetal reason 3 9.7 4 4.3 0 0.0 2 3.9 9 4.1
failed labour induction 0 0.0 0 0.0 0 0.0 1 2.0 1 0.5

Multivariate analysis of factors associated with planned cesarean section

Multivariate analysis (Table 6) showed different factors to be associated with planned CS

including socio-demographic, anthropometric, clinical, and obstetric factors. Health sector was
not significantly associated with the rate of planned CS after adjusting for important variables.
The odds of planned CS among women aged 20-35 and >35 years were 7.5 and 38.2 times that
odds among women aged <20 years, respectively. Income of >350 was significantly associated
with increased odds of planned CS by two times. Women with previous cesarean section had
much higher odds to be planned for CS (OR = 30.1). Breach presentation was associated with a
very high odds of planned CS (OR = 245). Women with multiple fetuses were 13.2 times more
likely to deliver via planned CS compared to women with single fetus.

Table 6. Multivariate analysis of factors associated with planned cesarean section

OR 95% confidence interval p-value

Lower Upper
Sector
Private 1.0
Public 1.5 0.7 3.2 0.251
Military 1.8 0.9 3.8 0.108
Teaching 1.7 0.8 3.4 0.134
Age
<20 1
20-35 7.5 0.6 92.0 0.114
>35 38.2 3.0 486.9 0.005
Income
≤350
>350 1.9 1.2 3.1 0.005
Number of fetuses
Single 1.0
Multiple 13.2 5.6 31.1 0.000
Previous cesarean section 30.1 19.0 47.6 0.000
Presentation 0.000
Cephalic
Breech 245.0 49.6 1211.6 0.000
Gestational age
≤31
32-36 8.0 1.6 39.9 0.011
≥37 2.8 0.6 12.9 0.199

Multivariate analysis of factors associated with emergency cesarean section

Women with previous cesarean section had twice higher odds to deliver via emergency CS (OR
= 2.2) compared to women with no previous CS. Breach presentation was associated with a very
high odds of emergency CS (OR = 58.7). Having a boy baby, gestational diabetes, and
hospitalization between 24 and 34 weeks of gestation were significantly associated with
increased odds of emergency CS.
Table 7. Multivariate analysis of factors associated with emergency cesarean section
Variable OR 95% confidence p-value
interval
Previous cesarean section 2.2 1.3 3.8 0.003
Presentation
Cephalic
Breech 58.7 12.7 271.9 0.000
Baby's gender
Female 1
Male 1.7 1.1 2.4 0.007
History of low/preterm delivery 3.6 1.1 12.2 0.041
Diabetes status
No Diabetes 1
Gestational diabetes 4.0 1.1 15.0 0.038
Pregestational diabetes 4.6 0.3 82.7 0.299
Hospitalization between 24 and 34 weeks of gestation 2.5 1.4 5.0 0.003

Pregnancy outcomes according to mode of delivery

Table 8 shows the pregnancy outcomes according to mode of delivery. About 45.6% of
newborns delivered vaginally had good Apgar scores at 1 minute (8-10) compared to 46.2% for
planned CS and 28.9% for emergency CS. The stillbirth rate was significantly higher (p=0.000)
for planned CS (1.7%) and vaginal delivery (1.5%) compared to emergency CS (0.5%).

Table 8. Pregnancy outcomes according to mode of delivery

Mode of Delivery Total
Vaginal delivery Emergency CS Planned CS

n % n % n % n %
Stillbirth 13 1.5 1 0.5 5 1.7 19 1.4
Apgar score 1 minute
Poor (0-3) 8 1 3 1.4 5 1.8 16 1.2
Intermediate (4-7) 426 53.4 152 69.7 144 52 722 55.8
Normal (8-10) 364 45.6 63 28.9 128 46.2 555 42.9
Apgar score 5 minute
Poor (0-3) 2 0.3 2 0.9 0 0 4 0.3
Intermediate (4-7) 19 2.4 18 8.3 24 8.7 61 4.7
Normal (8-10) 776 97.4 198 90.8 252 91.3 1226 95
Discussion

Rate of Cesarean Section in Jordan

The main finding of the study is the markedly high rate of CS (37.5%). The rate was 16.3% for
emergency CS and 21.2% for planned CS. This rate is much higher than the previously reported
rates from a study of maternal morbidity in Jordan (2007-2008) by the Higher Population
Council (27.7%) (28) and from the 2007 Jordan Population and Family Health Survey (18.5%).
The figure becomes more striking when compared to the previously reported data from seven
military hospitals across the country revealing a rate of only 8% for the period 1990-1992 which
increased to 10.9% for the period 1999-2001 (29).

Many researchers had studied the increase in rate of CS and tried to suggest solutions for the
problem. Robson et al. (30) suggested a Multidisciplinary Quality Assurance Program in each
delivery unit as cesarean delivery should not be considered in isolation from other outcomes.
Moreover, a Joint workshop of Eunice Kennedy Shriver National Institute of Child Health and
Human Development, Society for Maternal-Fetal Medicine, and American College of
Obstetricians and Gynecologists (31), addressed the concept of preventing the first cesarean.
The workshop addressed essential issues particularly those concerning definition of common
indications for cesarean delivery such as "failed induction" and "arrest of labor progress".
Authors recommended that health caregivers should get adherent to appropriate definitions and
enough time should be given before establishing the diagnosis of these indications.
Increasing Trend of CS and Its Possible Reasons
It is evident that there has been a rapidly increasing trend of CS in Jordan. In fact, an increasing
trend in cesarean deliveries has been observed almost everywhere during the past few decades.
In the United States, in 1970, the rate of cesarean was 5.5% as reported by the National Center
for Health Statistics and the Center for Disease Control and Prevention. Cesarean delivery
increased from 20.7% in 1996 to 31.1% in 2006 (32) and to 32.2% in 2014. (33).

In Egypt, cesarean rate increased from 4.6% to 10% between 1992 and 2000 (34). Ba’aqeel
(35) reported that over the period between 1997 and 2006, CS delivery rate in Saudi Arabia
increased from 10.6% to 19.1%.
The high rate of CS has well surpassed the recommendations of the WHO health experts who
considered the ideal rate for CS to be between 10% and 15%. It has been claimed that many
reasons may have led to this high rate of CS including:
 1) Timing of delivery: Obstetricians get used to time deliveries according to their schedules
and mothers get used to time deliveries according their convenient time or date.
2) Training of residents: Some residents may occasionally perform unnecessary CSs for
training purposes. The present study showed the highest CS rate in teaching hospitals.
However, the kind of women delivering in teaching hospitals may differ from women
delivering in other hospitals which may explain such higher CS rates in teaching hospitals.
3) Financial reasons.
4) Improvement in tools used in delivery rooms like those used in monitoring fetal heart and
fetal distress may contribute to the increasing CS rate.
5) Fear of complications may lead some obstetricians to perform CS without giving enough
time for a fair trial of labor.

Socio-demographic factors related to CS

This study showed that CS was significantly higher among women who were older than 35
years (44.6%). Peipert and Bracken observed that women whose age is > 30 years had a 70%
increased risk for cesarean delivery compared with women < 30 (36). Other studies showed that
increased maternal age is associated with an increase in CS rate. There is no satisfactory
explanation for this linear association between age and the CS rate. However, pelvic rigidity and
over care for premium babies in this group might be behind this increase.
Although we did not found a difference in CS rate according to women' education level, other
studies found that CS rate was significantly higher in highly educated women. Highly educated
women tend to be older than low educated women, because usually they get married and
pregnant at an older age.

Clinical characteristics related to CS

We observed that women with preeclampsia have an increased rate of CS. Preeclampsia is
known to be associated with a higher incidence of intrauterine growth restriction, fetal distress
and prematurity. Therefore, many mothers with preeclampsia are planned to deliver by CS.
Similar findings were reported from several studies (37). The real danger with preeclampsia is
that it prevents the placenta from getting the proper amount of blood needed which decreases the
oxygen flow to the baby leading to breathing problems and low birth weight. High blood
pressure overtime can lead to deterioration of mother and baby organs which may be fatal.

Our study showed that CS rate was significantly higher in mothers complaining of gestational
diabetes or pregestational diabetes. These results are consistent with a study done in University
of Liverpool, which showed a high CS rate (67%) in women with type 1 and type 2 diabetes
compared to 21% in other women. It has been recently discovered that women with diabetes
have impaired uterine contractility (38).

Reasons for CS
CS is done either for emergency or planned reasons. As regard to emergency CS, the most
common reported reasons in the current study were prolonged fetal distress and abnormal
presentation like breech or transverse presentations. These results are consistent with the
findings of a study in Bangladesh where the most common reasons cited for emergency CS were
fetal distress and prolonged obstructed labor (39). Another study was done to determine the
leading indications for emergency CS in West Visayas State University from January 2005 to
December 2007. Dystocia (30.8%) emerged as the leading indication for emergency CS
followed by malpresentation (23.8%) (41), a finding that is consistent with findings of the
current study.

In regards to planned CS, the most frequent reason cited was scarred uterus which mostly
indicates previous CS and abnormal presentation mostly (breech). These results are consistent
with a study done in Bangladesh where the most common reasons cited for planned CS were
previous CS and poor obstetric history. It’s claimed that if pregnant women had a past history of
CS the next delivery will be mostly by CS, and if pregnant women had delivered the last two
deliveries by CS it will be an indication for CS (39). Overall, our findings are similar to most
previous studies showing that the main reasons for cesarean delivery are previous cesarean
delivery, breech presentation, abnormal labor (dystocia), and fetal distress. (24).
Among the proposed factors contributing to the increase in cesarean is mother's desire. Mother's
desire in the current study was one of the main reasons for planned CS. Results from a previous
study in the same population of Jordan (40) showed that the reason for preference of CS was
simply to avoid pain of vaginal delivery. Consistent with the current study, a study done in UK
and Northern Europe showed that the CS rate upon mother request was around 6% to 8% of all
primary cesarean sections. Different figures were reported for CSs upon mother desire from
USA (11%) (27,41) and Australia (17%) (30). Dobson found that CS rate is often attributed to
an increase upon mother request (42).

On the other hand in a previous study of maternal morbidity in Jordan (2007- 2008), mother
desire accounted for less than 1% of cesarean deliveries (The Higher Population Council, 2008).
It may be seriously doubted whether CS upon mother request is solely responsible for the
worldwide increase in cesarean rates. But there is a solid belief that scientific progress, social
and cultural changes, may lead to change in mother desire and attitude to CS.

Conclusions

Jordan has a markedly high rate of CS (37.5%). The rate of planned CS is higher than that of
emergency CS. Scarred uterus and multiple fetuses are the most common reasons for planned
CS. The main reasons for emergency CS are prolonged fetal distress, obstructed labor, and
abnormal presentation. The distribution of reasons for planned and emergency CS varies
according to health sector.
Age >35 years, previous cesarean section, breach presentation, and multiple fetuses were the
significant predictors of planned CS. Health sector was not significantly associated with the rate
of planned CS after adjusting for important variables. On the other hand, previous cesarean,
breach presentation, having a boy baby, gestational diabetes, history of low/preterm delivery and
hospitalization between 24 and 34 weeks of gestation were significantly associated with
increased odds of emergency CS. The rate of stillbirth was significantly higher for planned CS
(1.7%) and vaginal delivery (1.5%) compared to emergency CS (0.5%). However, the small
number of stillbirths in this study make difficult to reach a conclusion on its association with
mode of delivery.
Suggestions for Future Research
Future research is needed to explore the nonclinical causes of CS like attitudes, behaviors, and
skills of obstetricians as well as the social, economic, and legal environment in the country. We
need also to understand the preferences of women in this regard. As much of the offered causes
for cesarean delivery in this study are to an extent subjective and dependent on the judgment of
the physician, research may be directed to uncover the true causes for this alarming health
problem. The effects of caesarean section rates on other outcomes, such as maternal and
perinatal morbidity, pediatric outcomes, and psychological or social well-being are still unclear.
More research is needed to understand the health effects of caesarean section on immediate and
future outcomes
Recommendations

Based on the available data and using internationally accepted methods to assess the evidence
with the most appropriate analytical techniques, caesarean sections are effective in saving
maternal and infant lives, but only when they are required for medically indicated reasons. At
population level, caesarean section rates higher than 10% are not associated with reductions in
maternal and newborn mortality rates. Caesarean sections can cause significant and sometimes
permanent complications, disability or death particularly in settings that lack the facilities and/or
capacity to properly conduct safe surgery and treat surgical complications. Therefore, we
recommend the followings:
1. A multidisciplinary quality assurance program should be established in all Jordanian
facilities in which delivery occurs. As most CSs are currently based on physician’s
judgment, it may be extremely useful to develop and strictly implement national
guidelines for performing CSs.
2. Implement a policy of mandatory second opinion for all Cs (planned or not).
3. Make written guidelines available for all physicians at the hospital.
4. Implement the monthly medical audits of the obstetrical practice.
5. Multifaceted strategies, based on audit and detailed feedback, are advised to improve
clinical practice and effectively reduce caesarean section rates.
6. Caesarean sections should ideally only be undertaken when medically necessary. Every
effort should be made to provide caesarean sections to women in need, rather than
striving to achieve a specific rate.
7. In making plans for delivery, physicians and patients should consider a woman’s chance
of a successful vaginal birth after cesarean as well as the risk of complications from a
trial of labor.
8. Implement in case of induction a policy of informed consent that allows the mother to be
fully informed of the possible consequences and benefits of an induction for non medical
reasons.
9. Get a commitment from hospital obstetric departments to work on lowering the C-
section rate.
10. Alert patients about the true risks of major abdominal (C-section) surgery, compared to
normal vaginal deliveries.
11. Provide more training and support for women giving birth to twins to do so vaginally.
 12. Mobilize an effort to evaluate the effectiveness and need for labor induction, continuous
fetal monitoring and epidurals because all of these procedures can lead to more C-
sections.

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